EBQ:Catheter related infections

Complete Journal Club Article

Marik PE et al. "The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis.". Critical Care Medicine. 2012. 40(8):2479-85.
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Clinical Question

What is the rate of catheter-related infections of non-tunneled catheters placed at the femoral vein site as compared with subclavian and internal jugular sites?

Conclusion

Although earlier studies showed a lower risk of catheter related bloodstream infections when the internal jugular was compared to the femoral site, recent studies show no difference in the rate of catheter-related bloodstream infections between the three sites.

Major Points

3230 catheters were placed in the subclavian vein, 10,958 in the internal jugular and 3,188 in the femoral vein for a total of 113,652 catheter days.
Avg catheter related blood stream infections density was 2.5 per 1,000 catheter days (range 0.6–7.2).
There was no significant difference in the risk of catheter related bloodstream infections between the femoral and subclavian/internal jugular sites in the two randomized controlled trials
There was no significant difference in the risk of catheter related bloodstream infections between the femoral and subclavian sites.
The internal jugular site was associated with a significantly lower risk of catheter-related bloodstream infections compared to the femoral site
- Risk ratio 1.90; 95% CI 1.21–2.97, p = .005, I2 = 35%.
- This difference was explained by two of the studies that were statistical outliers.
  - When these two studies were removed from the analysis there was no significant difference in the risk of catheter related bloodstream infections between the femoral and internal jugular sites' (risk ratio 1.35; 95% confidence interval 0.84–2.19, p = 0.2, I2 = 0%).
Meta-regression demonstrated a significant interaction between the risk of infection and the year of publication (p = .01), with the femoral site demonstrating a higher risk of infection in the earlier studies.
There was no significant difference in the risk of catheter related bloodstream infection between the subclavian and internal jugular sites.
A meta analysis of this data demonstrates that there was no difference in the risk of deep venous thrombosis when the femoral site was compared to the subclavian and internal jugular sites combined.

Study Design

Systematic Review and meta-analysis

Population

Data Sources: MEDLINE, Embase, Cochrane Register of Con- trolled Trials, citation review of relevant primary and review articles, and an Internet search (Google).
Study Selection: Randomized controlled trials and cohort studies that reported the frequency of catheter-related bloodstream infections (infections per 1,000 catheter days) in patients with non-tunneled central venous catheters placed in the femoral site as compared to subclavian or internal jugular placement.
Data Extraction: Data were abstracted on study design, study size, study setting, patient population, number of catheters at each insertion site, number of catheter-related bloodstream infections, and the prevalence of deep venous thrombosis.
- Studies were subgrouped according to study design (cohort and randomized controlled trials).

Included Studies

Two randomized controlled trials (1006 catheters) and 8 cohort (16,370 catheters) studies

Interventions

Comparison of catheter care bundles and practices to reduce catheter-related bloodstream infections
Interventions included maximal sterile barrier precautions, chlorhexidine skin preparation, and optimal site selection
No standardized single intervention; study examined the association of various practices with infection rates

Outcomes

Primary Outcome

Catheter-related bloodstream infection rate: 3.2 per 1,000 catheter-days (overall)

Secondary Outcomes

Subclavian site had lowest infection rate compared to internal jugular and femoral sites
Duration of catheterization was the strongest predictor of infection risk
Antibiotic-impregnated catheters showed reduced colonization rates

Criticisms

Limited by inclusion of mostly observational cohort studies (only 2 RCTs out of 10 studies)
Heterogeneity between studies in definitions of catheter-related bloodstream infection
Two statistical outlier studies significantly influenced the IJ vs femoral comparison; excluding them changed results
Did not account for differences in patient populations that influence site selection
Does not address other complications such as pneumothorax or arterial puncture

Funding

Not specified in the publication

References

Marik PE et al. Crit Care Med. 2012;40(8):2479-85. PMID 22809915

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